Provider Demographics
NPI:1386912954
Name:WISCONSIN SPINAL REHABILITATION CENTER S.C.
Entity type:Organization
Organization Name:WISCONSIN SPINAL REHABILITATION CENTER S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:GORDON
Authorized Official - Last Name:FRIEDRICHS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:262-642-4100
Mailing Address - Street 1:3224 W MAIN ST STE E
Mailing Address - Street 2:PO BOX 984
Mailing Address - City:EAST TROY
Mailing Address - State:WI
Mailing Address - Zip Code:53120-1152
Mailing Address - Country:US
Mailing Address - Phone:262-642-4100
Mailing Address - Fax:262-642-4101
Practice Address - Street 1:3224 W MAIN ST STE E
Practice Address - Street 2:
Practice Address - City:EAST TROY
Practice Address - State:WI
Practice Address - Zip Code:53120-1152
Practice Address - Country:US
Practice Address - Phone:262-642-4100
Practice Address - Fax:262-642-4101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-09
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3170111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty